Occurrence Briefs are concise reports that detail the facts surrounding a transport safety occurrence, as received in the initial notification and any follow-up enquiries. They provide an opportunity to share safety messages in the absence of an investigation.
On 25 March 2021, at about 2130 Eastern Daylight-saving Time, following a rostered day of flying duties, the pilot of the Diamond DA42 aircraft commenced taxiing at Bankstown Airport, New South Wales, for a session of night circuits to maintain currency.
After the aircraft had rolled forward slightly, the pilot noticed they had left their iPad on the apron and decided to retrieve it before proceeding any further. The pilot engaged the park brake with both engines running and exited the cockpit onto the aircraft’s wing. While the pilot was on the wing, the aircraft moved forward, causing the pilot to lose balance and fall backwards onto the tarmac. The pilot sustained minor hand and leg injuries.
The parking area had a slight decline and the aircraft rolled down the slope. The right wing struck a hangar, and the aircraft went through a perimeter fence, resulting in minor damage to the wing tip and various panels around the nose section of the aircraft.
The pilot reported being unable to regain entry to the cockpit as it rolled away. Once the aircraft had stopped moving, the pilot entered the cockpit and shut down the engines before securing the aircraft.
Operation of the park brake is achieved by applying pressure to the toe brake pedals and moving the park brake selector down until it catches. This traps the hydraulic fluid in the brake units and the wheel brakes stay on. The pilot reported being unsure if sufficient pressure was applied to the brake pedals when activating the park brake. The operator advised that following the incident, the park brake was checked and reported to be serviceable.
The pilot reported that at the time of the incident they had been awake for 17 hours. The ATSB publication Fatigue experiences and culture in Australian commercial air transport pilots references studies that found periods of extended wakefulness increase the risk of experiencing a level of fatigue demonstrated to adversely affect performance.
As a result of this occurrence, the operator advised the ATSB that the company has introduced a refresher course for all flying staff regarding fatigue management and responsibilities.
A more appropriate course of action would have seen the pilot shut down the engines before securing the aircraft with the park brake and then exiting the aircraft to retrieve the iPad from the apron. Lapses in decision making can result from extended periods of wakefulness. The ATSB SafetyWatch highlights the broad safety concerns that come out of our investigation findings and from the occurrence data reported to us by industry. One of the safety concerns is Fatigue.
About this report
Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report, and allow for greater industry awareness of potential safety issues and possible safety actions.
|Date:||25 March 2021||Investigation status:||Completed|
|State:||New South Wales|
|Release Date:||18 June 2021||Occurrence category:||Serious Incident|
|Report status:||Final||Highest injury level:||Minor|
|Aircraft manufacturer||Diamond Aircraft Industries|
|Type of operation||General Aviation|
|Damage to aircraft||Minor|
|Departure point||Bankstown, NSW|